Cognition and the Self-Management of
Chronic Disease
Dr Kerrie Shiell
Clinical Neuropsychologist
Dr Chelsea Baird
Geriatrician
Learning Objectives
What is the association between chronic disease and cognition?
Explain neuropsychological profiles in CCF, DM and COPD and cognitive domains
How do we identify these changes?
How does cognitive impairment impact on self-management?
Strategies to overcome these deficits
Case Study: Lynette
71 yo F PMH:
T1DM (neuropathy, gastroparesis) 55 years
Parkinson’s Disease 6 years
Hearing Impairment
Visual impairment
Lives with partner
Tertiary educated and managed own businesses Independent, nil services
Ceased driving aged 69 years
Medications (via Webster pak)
Insulin: Lantus 43 units nocte, tds Actrapid
Cholecalciferol 1000 units daily
Domperidone 10mg tds
Irbesartan 75mg daily
Pregabalin 37.5mg nocte
Movicol 1-3 sachets daily
Bisalax 5mg tds prn
Sinemet 100/25mg tds
Rotigotine Patch 16mg/ 24 hours
2014: Admission for unstable BSL’s
Intensive diabetes education
Site rotation, erratic oral intake, ketone testing, sick day management
2015: Admission for Severe hypoglycaemia
Adjustment guidelines from endocrinologist
1 unit for small carbohydrate meal
2 units for usual meal
3 units large carbohydrate meal
If BGL >12.0mmol/L have one extra unit
Discussed: injection times, hypoglycaemia management, BGL patterns, BG testing times and targets, site rotation, long term principals
“Lynette overwhelmed with diabetes management…”
2015: Elective admission for stabilisation and assessment of BSL’s
Poor understanding of CHO and impact on BSL’s
Unable to recall information from previous session
Using insulin at inconsistent times
MMSE 30/30; MOCA 26/30
August 2016: Declining/ fluctuating cognition noted
Unable to make corrections
Partner taking over BGL management
Conflict
District nursing engaged: client declined
Frustration from HARP, GP, DNE
Referral to CDAMS
Possible diagnoses?
Vascular dementia
Impact of erratic BSL’s
Depression/ anxiety
Parkinson’s disease with dementia
Lewy Body Dementia
Neuropsychological Assessment
Anxious ++
Multiple domains impaired
Reduced processing speed
Visuo-spatial impairment
Semantic verbal fluency
Set shifting and sequencing
Confrontational naming
Unable to retain new information unless presented in simple format and repeated; responded to prompts to retrieve that information
Likely Parkinson’s Disease Dementia as well as vascular burden
Outcome
Engaged in the process
ENDO: re-engaged in diabetes clinic (previously discharged due to non-
attendance); ‘?cognitive impairment’ documented; aiming for less titration of BSL’s, aiming to avoid hypo’s (aim HBA1c 7.5%- 8.5%)
Partner taken over insulin injections and BSL monitoring, more engaged in OP appointments
‘Intensive appointments’ in person or over phone with DNE
LIBRE monitor
Self-reported a reduction in depression and anxiety symptoms
No hospitalisations >18 months
Cognitive impairment in Chronic Disease: How common is it?
Prevalence of cognitive impairment
heart failure 43%
32% in COPD
35-44% in diabetes
T2DM:
RR 1.9 dementia
RR 4.3 for insulin-requiring diabetics
Cannon et al. J Card Failure, 2017 Yohannes et al. JAMDA, 2017 Munshi et al. Diabetes, 2015 Ott et all. Neurology 1999
Other chronic conditions associated with cognitive impairment
Chronic Kidney Disease
Stroke
Hypertension
Gout
Hypercholesterolaemia
Rheumatoid arthritis
Obstructive sleep apnoea
Snowden. Int J Geriatr Psych. 2017
Dementia and Co-morbidities
PWD have mean average 2.4 comorbidities, 5.1 prescribed medications
Increased risk of institutionalisation
Increased risk of dependence in ADL’s
Shorter survival
Schubert et al. JAGS 2006 Melis et al. PLOS One 2013 Aguero-Torres et al. J Clin Epidem 2001 Snowden et al. Int J Geriatr Psych 2017
HARP target population
The two streams of care provided by HARP are chronic disease and aged and complex care.
The chronic disease stream includes:
• chronic heart disease
• chronic respiratory disease
• diabetes
• other chronic disease.
The aged and complex care stream includes:
• complex aged care
• people with complex psychosocial needs
• people with complex needs requiring integrated care.
Why does cognitive impairment often coexist with chronic disease (1)?
Complications of disease on the brain
COPD: Chronic inflammation, hypoxia, hypercapnia
Heart Failure: Cerebral hypoperfusion, pro- inflammatory state
Diabetes: Chronic small vessel ischaemia, strokes,
multi-infarct dementia
Why does cognitive impairment often coexist with chronic disease (2)?
Shared risk factors (Smoking, hypertension, diabetes)
Poor disease control also negatively impacts directly on cognition (e.g. hyperglycaemia and confusion)
Fluctuating disease course
Capacity to self-manage also fluctuates
Mood
Physician recognition of Cognitive Impairment
Women aged >75 years (Women’s Memory Study)
Physicians involved their care over the last 12 months
General medicine, cardiology, respiratory medicine, endocrinology, rheumatology, family medicine, neurology, gynecology
12% had additional Geriatrics qualifications
Inpatient and outpatient medical records assessed
Chodosh et al 2004, JAGS
Current Practice for PWD and Chronic Disease
HCP’s are often totally unaware of a diagnosis of dementia
Little evidence of tailored approaches to care
PWD often require someone else to help navigate our healthcare system
Families often responsible for information transfer between treating HCP’s
No routine approach to involvement for carers in decisions or discussions
Clinical guidelines rarely offer alternate management approaches for PWD
Transition from self-management to dependency (sudden or gradual)
Bunn et al. Health Serv Deliv Res 2016
But what is cognition?
Attention and working memory
Ability to sustain or divide attention
How much info they can take in and work with
Processing Speed
Relates to how quickly you can:-
come up with a response
work through a problem
process what is being said to you
But what is cognition?
Language
Expressing yourself
Having the language to talk about your needs
Find words to describe things
Comprehension
Understand what the doctor is telling them
Understand instructions to deal with new treatments
Reasoning ability
Think flexibly about your needs to generate solutions
But what is cognition?
Visual spatial function
Understanding of self in space
Personal space – broader environment
“Losing the mental map”
Memory
Verbal and Visual modality
Registration
Impacted by attention
Recall
Freely recalling following a delay
Retrieval
Need prompting to draw the information out
But what is cognition?
Executive Function
Another umbrella term
Abstract thinking, reasoning, planning,
Initiation, motivation, decision making,
Mental flexibility, self-monitoring
Cognitive Profiles in chronic disease (1)
Different to common presentations of other dementias
(E.g. Alzheimer’s dementia may present with
memory impairment)
Cognitive Profile in Chronic Disease (2)
Diabetes
Attention, psychomotor speed, visual perception, EF
COPD
Attention, memory, motor, executive function
Heart Failure
Attention, executive function, language, processing speed
Executive Dysfunction
Disinterested
Not engaging
Non-adherent
Making a choice
Stubborn
Personality
Not following through on recommendations despite an apparent understanding
Difficult patient
HARP Clinicians: Red flags for Cognitive Impairment in Chronic Disease Hygiene/ Self-care
Environment: clutter, Cleanliness of house Insulin use and BSL monitoring
Collateral history
Poor inhaler technique
Ability to pay attention to information or recall between sessions Recent hospitalization
Forgotten meals/ empty fridge/ Weight loss Medication mismanagement
Management of hypo Frequent falls
Repetitive behaviours Missing appointments Not checking his fluids
Challenge: Cognitive Impairment Red Flags in
the context of chronic disease management
Self-management and chronic diseases- 5 key steps
Step 1: Identifying problems and generating realistic solutions
Step 2: Decision-making: acting in response to changes in disease condition
Step 3: Finding and utilizing appropriate resources
Step 4: Working with health care providers to make informed choices about their treatment
Step 5: Taking action
Lorig & Holman, 2003
How does cognition impact on the self- management key steps?
Step 1: Identifying problems and generating realistic solutions
Executive function, memory, language, attention
Step 2: Decision-making: acting in response to changes in disease condition
Executive function, memory
Step 3: Finding and utilizing appropriate resources
Executive function, memory, language, visuo-spatial, praxis
Step 4: Working with health care providers to make informed choices about their treatment
Language, executive function
Step 5: Taking action
Executive function, memory
Ibrahim et al. J Multidisc Healthcare 2017
A word about carers
9 skills in family caregiving process
Monitoring the person’s condition
Interpreting observations
Making decisions about which course of action
Taking appropriate action
Making adjustments
Accessing external resources
Working together with the person receiving care
Navigating the health system
Providing hands on care
Schumacher KL, Stewart BJ, Archbold PG, Dodd MJ, Dibble SL. Res Nurs & Health. 2000, 23.
How can we identify these changes?
MMSE
Quick but it’s a blunt instrument
Doesn’t look at the function of about 2/3rds of the brain
MoCA
More sensitive tool
Captures more brain function
Still quick
BUT still a screen
Making the most of cognitive screens
The global score is not the whole picture…
What could individual errors mean?
Do these correlate with your observations?
Identifying areas of weakness
Assessment, Observation and Informant report
Attention and Working Memory
MOCA
Reciting digits forward and backward; serial 7’s, reading the list of letters
Observations
Limited ability to take on multi-step instructions
Forgetful, confused and distractible
Processing Speed
MOCA
Not directly measured but observable in the clients approach in timed tasks
Observations
Slow speech rate, response latency, difficulties with comprehension
Identifying areas of weakness
Language
MOCA
Naming (word-finding), Sentence repetition task, Fluency
Observation
Non-fluent speech, filler phrases
Difficulty coming up with ideas or solutions - particularly to open-ended questions
Problems understanding instructions or conversation
Visual spatial function
MOCA
Cube task (impacted by education), Trails B (switching numbers and letters)
Clock Drawing
Observation
Getting lost, no personal space
Problems with dressing, coordination of utensils/equipment
Identifying areas of weakness?
Memory
MOCA
Registration of word lists, delayed recall, recognition task
Observation
Repetitive in conversations, forgetting medication
Misplacing things, forgetting appointments
Executive Function
MOCA
Approach to the clock drawing (planning/organisation),
Word fluency (idea generation), Trails B (disinhibition, set-shifting)
Observations
Impulsive, overly familiar, disorganised thinking, child-like, poor initiation
Tailoring strategies to fit
Understanding the cause is part of the picture…
BUT what are the implications for self-management in chronic
disease??
Break
Impact of Memory Loss on Self-Management
•
Taking medications at the wrong time
•
Struggling to learn and/or retain inhaler techniques and failure to recall the required steps
•
Forgetting medications or insulin injections
•
Forgetting appointments
•
Forgetting to eat on time or prior to exercise
Memory Strategies
•
The deeper the processing the more likely the information will stick…
•
Simplify
•
Simplify medication regimes
•
Limit the dosing frequency if possible
•
External Aids
•
Alarms, Diaries, Altogether Book, dosette boxes
•
Consider clinic reminders
•
Written action plans
•
Involve care-givers and supervised exercise programs
Memory Strategies
•
Association
•
Acronyms (e.g., KPUP)
•
Visual Imagery (e.g., Remembering names or routes)
•
Prospective Memory (i.e., recalling future events, shopping)
Memory Strategies
•
Rehearsal
•
General Points
• Summarise and rehearse key points
• Provide information in manageable chunks
• Check techniques at every clinic visit
•
Rehearsal Techniques
• Spaced Retrieval
• Errorless Learning
• Chaining
Errorless Learning and Chaining
•
Break task into steps
•
Demonstrate and label all the steps in the task sequence
•
Teach step one
• Say: “When you need to perform (specific task) you should begin by performing step 1”
• Guide patient, as needed through step 1
•
Teach Step Two
• Say: “After you do 1, you should do 2. What should you do after you do 1?”
• Guide patient, as needed through step 1 and 2
Impact of Executive Dysfunction on Self-Management
•
Problem-solving difficulties
•
Unable to integrate ideas into practice
•
Unable to recognise or treat symptoms
•
Unable to generate solutions or identifying appropriate options
•
Insight
•
Self-report not the best assessment of treatment adherence
•
Failure to recognise build up to an adverse event
•
Recognising the importance of self-care plans
Impact of Executive Dysfunction on Self-Management
•
Planning and sequencing
•
Impacting ability to utilise inhaler in COPD
•
Shifting thinking
•
Refuses any new treatment
•
Trouble adopting new treatment approaches
•
Difficulty generating new ideas to assist with management
•
Trouble negotiating goals of care
Addressing Executive Dysfunction
•
Problem-solving difficulties
•
Repetition of instructions and education at each visit
•
Providing information in different formats
• Verbal (consider your language)
• Visual – write it down, provide diagrams
• Use demonstration
•
Issues with Insight
•
Predict-perform procedures
Addressing Executive Dysfunction
•
Difficulty Shifting Behaviours
•
Recognise this “stubbornness” for what it is
•
Avoid labels such as non-compliant
•
Make small incremental changes
•
Avoid complex regimes
•
Ask forced-choice and closed questions
•
Use as many external aids and reminders as is necessary (including care-
givers)
Addressing Executive Dysfunction
Planning and sequencing
Devices: turbuhalers better than metered dose inhalers; simplify where possible
Review technique at every opportunity and re-educate
Let’s
practice…
• Divide into groups
Case Studies
• What other information would be useful?
• What are the key factors impacting on self-management?
• What strategies might be useful for the people in your case studies?
Key Questions
Implications for practice (1)
Poor disease control could be due to an unrecognized cognitive impairment
Cognitive Assessment must consider executive functions (e.g. MOCA vs MMSE)
Role of the Multidisciplinary team (everyone’s job):
Checking in on patient’s understanding
Assess ability to undertake complex daily actions
Focus on the functional consequences of different areas of cognitive impairment
Assess patient capability of undertaking the tasks required for self- management
Implications for practice (2)
The impact of dementia on a patient’s ability to self manage will vary according to cognitive domains affected, severity of the impairment and complexity of the self-care task.
Tailoring self-management support is key; assess current capabilities, identify potential barriers to successful self-management, maintain
independence.
This approach must be modified as cognitive function continues to
deteriorate, therefore, ongoing monitoring of patient health and capacity
for chronic disease self-management is essential
